Publications (2)4.09 Total impact
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ABSTRACT: To determine interobserver variability between an emergency medicine consultant and nurse practitioners for the use of the Wells score in the assessment of deep vein thrombosis (DVT) in the emergency department. A prospective cohort study was undertaken in a population of 100 cases of suspected DVT. The Wells score reading from the consultant was compared with the reading of the nurse practitioners. Consultant and nurses were blinded to each other's assessments. The nurse practitioners were trained in interpreting the Wells score by assessing 100 patients together with the consultant before the start of the study. Consultant and nurse practitioner assessments resulted in the same final Wells score in 81% of cases (simple agreement), with a kappa score of 0.74 (95% CI 0.63 to 0.84). If the nurse practitioner score had been followed in preference to the consultant assessment, this would have resulted in eight patients being assessed in a lower risk algorithm (8%). There is good interobserver agreement between consultant and nurse practitioners for the use of the Wells score as part of a DVT assessment service within the emergency department. Pretest scoring is pivotal to integrated strategies for the exclusion of DVT. The Wells score is a robust and reliable tool for pretest scoring in the emergency department regardless of the grade of the assessor, provided there is adequate training in its use.
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ABSTRACT: It has been proposed that patients who develop Clostridium difficile-associated disease (CDAD) do so because they are unable to mount an adequate immune response. Serum was collected from three groups of elderly in-patients: (i) cases (n=21) of CDAD, being toxin A/B-positive; (ii) carriers (n=21) asymptomatic for CDAD (no diarrhoea) but at least toxin or culture positive; and (iii) controls (n=26) asymptomatic for CDAD and negative for both C. difficile toxin and culture. The age and gender of each group were compared, and the colonizing strains were ribotyped and toxinotyped. Serum antibodies (IgG and IgM) were measured by ELISA using different antigen preparations: EDTA extract (containing cell-surface proteins and carbohydrates), guanidine hydrochloride extract (surface-layer proteins), aqueous phenol-extracted lipocarbohydrate (LC); crude toxin (dialysis culture supernatant) and purified toxin A. LPS from Escherichia coli was used as a control antigen. Antibodies were also tested for toxin neutralization on tissue monolayers and for binding to EDTA-extracted antigens by Western blotting. IgG antibody measurements to cytomegalovirus (CMV) were included as an indicator of potential immunosenescence. Results showed that the patient groups were well matched by age and gender, and the colonizing strains were similar in cases and carriers, being predominantly ribotype 001 and toxinotype 0. By ELISA, IgG levels to most of the antigens were highest in the cases and lowest in the controls, with the exception of antibodies to the LC, which were higher in the controls than the cases. Levels in the carriers tended to be of intermediate level or similar to the controls. For all antigens, the levels of IgM were not significantly different among cases, carriers and controls. Serum from all groups was able to neutralize the cytotoxic action of toxin on both Vero and Caco2 cells, and all to a similar extent. Western blots showed an overall higher level of IgG antibodies to the EDTA-extracted antigens in the cases. The results of the CMV ELISA showed that specific IgG was detected in more cases (78%) than carriers and controls (both 65%), but this difference in seropositivity was not significant. The conclusion is that, during symptomatic infection, patients respond to protein antigens of C. difficile in a manner typical of a secondary antibody response, with no evidence that an inability to respond predisposes to the appearance of symptoms.
Queen Margaret UniversityEdinburgh, Scotland, United Kingdom